Record keeping and guidelines 1

Question 1

give 4 reasons for the importance of keeping good clinical records and give examples for each point

Answer 1

• To retain clinical information
  e. g. otherwise how would we reorder specs if broken? i.e. don’t have to waste time repeating tests/measurements
• To identify trends
  allows us to detect progression e.g. VF’s and glaucoma
  research and statistical analysis
• To protect our patients
  allows us to consider long-term needs of the patient
• To protect ourselves

Question 2

give 2 risks of what could happen from not keeping good clinical records in order to protect ourselves

Answer 2

• an allegation that an optometrist’s “fitness to practice” is impaired (GOC)
• or against a “negligence” case in the civil courts

could be brought and won against us and they will be looking at your records

Question 3

out of an analysis of 50 cases taken against optometrists (both GOC Fitness to Practice cases and cases in the civil courts) from Woodward 2006, name which disease accounted for 15, 13 and 6 cases

Answer 3

• 15 cases were related to glaucoma
• 13 cases were related to retinal detachment.
• 6 cases were related to papilloedema

Question 4

list 5 of the most common cases taken against optometrists

Answer 4

• contact tonometry
• cataracts
• retinal detachment
• glaucoma
• tumours

Question 5

why is contact tonometry a common case taken against optometrists and what can be difficult about this

Answer 5

• Epithelial damage can be painful
• Patients or their advisers try to blame later eye infections on damage caused by tonometry
• Hard to prove the link

Question 6

how can you help the fact that it is hard to prove a link between a patient who has had an infection post contact tonometry and is blaming you for this

Answer 6

you have to document everything down

e.g. of any staining pre and post GAT and the advice you have given to the patient for evidence

Question 7

why was cataract a common case taken against optometrists and what was difficult about it

Answer 7

• In the past we often did not tell patients about early cataracts (maybe because px had another more important pathology in their eye which could’ve been causing the vision reduction)
• But patients often found out later and could be upset
  Now “considered reasonable for patients to expect to be told as much as possible about their clinical condition”
• Hard for patient (or lawyers) to prove what damage was caused

Question 8

why is retinal detachment a common case taken against optometrists and what should be done to avoid this

Answer 8

• Classic symptoms of flashes, floaters & curtain across vision require dilation and Volk examination
• But patients may not explain symptoms well and retinas can detach at any time, or may not have the classical signs and symptoms
• No corridor consultations: must book a full eye examination as we have responsibility for them, make sure you always dilate the patient, if you can’t find anything and their if their vision is still reduced then refer the patient to the HEs

Question 9

how do you avoid glaucoma being a common case taken against optometrists, state 3 things you should do

Answer 9

• Look out for patients with risk factors e.g. family history, African origin etc.
• In “at risk” patients do tonometry, disc assessment and fields (make these tests priority if you are short of time)
• Make sure your records are of good quality

Question 10

why is tumours a common case taken against optometrists and what should be done to avoid this

Answer 10

• Very difficult area for optometrists (e.g. a choroidal melanoma is hard to see with direct ophthalmoscope as its not 3D view, so its hard to tell if its just a naevus thats flat or a raised tumour, so must do a volk examination)
• Some tumours are very hard to detect and it is hard to say how long they have been present when they are detected
• When in doubt refer!

Question 11

when is a Bolam test carried out and under which conditions can it work

Answer 11

• In clinico-legal cases an optometrist’s actions can be successfully defended if it is shown that:
• the eyecare that they provided is supported by the actions of a significant body of reasonably competent optometrists
• if you claim to be an expert in a particular area of optometry then the standard you achieve is that expected of the average expert in that field
  e. g. if you’re an additional supply optometrist, you will be compared to another additional supply optometrist and not an ordinary optometrist. so its like for like.

Question 12

what 2 cases does the Bolam test apply to

Answer 12

• civil litigation
  and
• disciplinary cases instigated by the General Optical Council

Question 13

what did the Bolitho precedent establish and explain what it means and the difference and similarity it has with the Bolam test

Answer 13

that a court is “not necessarily bound by expert opinion”

but some optometrists will have done things differently to others with the same outcome

It is how the Bolam test still stands, except when “a judge can be satisfied that the body of expert opinion cannot be logically supported at all”

= the case can be referred by an expert opinion and that whatever you do needs to be a logical decision

Question 14

give 3 reasons to the Importance of keeping good clinical records for protecting ourselves

Answer 14

• Records completed at the time of the examination are admissible in evidence
• Quality and quantity of information on the record card will significantly affect the optometrist’s ability to defend charges
  Choose a record occasionally and assess it!
• Clinical records themselves can become the subject of scrutiny by GOC

Question 15

what should you always record with the results of your ocular examination

Answer 15

Always record basic normalities relating to the external eye, media and fundus

Question 16

what it the disadvantage if your records are inadequate

Answer 16

then it is very difficult to defend yourself against “failure to include a relevant test”

Question 17

If you have obviously done the test but missed something then the prosecuting lawyer has to…

Answer 17

prove that you “failed to provide an adequate standard of care”

e.g. if a patient doesn’t have a headache, then still state on your record that they don’t have headaches

Question 18

list the 5 steps of what can happen if you don’t record basic normalities and your patient has developed glaucoma

Answer 18

• You are in court defending your actions on a patient who has developed glaucoma
• Patient claims you missed the glaucoma
• Lawyer is asking you about your recording of the appearance of the disc
• You didn’t record anything about the disc because it was completely normal. Your habit is to only record disc details if there is anything abnormal to record
• Problem is that your records are inadequate and make it difficult to defend yourself against “failing to include a relevant test”

Question 19

what is writing “Fundus Normal” not acceptable as

Answer 19

a global comment relating to a whole examination of the eye or of the fundus

Question 20

list 3 examples of record keeping your should avoid making a habit of and explain why to each example

Answer 20

• Writing “Fundus Normal” is not acceptable as a global comment relating to a whole examination of the eye or of the fundus
• Avoid “NAD” in record keeping
  CoO advise that “NAD is frequently used but is not recommended”
• Avoid ticks as the best you can argue is that they indicate that a test or tests were carried out but not that the result was necessarily normal
  “Media √” means “absolutely nothing” according to AOP

Question 21

why should you avoid ticks on your record card

Answer 21

you can argue is that they indicate that a test or tests were carried out but not that the result was necessarily normal
“Media √” means “absolutely nothing” according to AOP

Question 22

note down what the absolute minimum to record on record cards in a patient who is “normal” would be

Answer 22

External eyes - Normal
Media - Clear
Disc - Normal
and note the C/D ratio and appearance of neuro-retinal rim
Vessels - Normal with A/V ratio recorded
Peripheral fundus - Normal
Macula - Normal (if its an elderly px, you can also say “no drusen seen”, if they’re in the age to get AMD)

Question 23

what 2 extra things can you add to your absolute minimum record card to make it better

Answer 23

• If you used a slit lamp, which is preferable, record that you did
• If you used a Volk lens, record that you did, and record the type

Question 24

what is the CoO “Guidance for Professional Practice” divided into and name each one

Answer 24

Divided into 4 domains:

• Knowledge, skills and performance
• Safety and quality
• Communication, partnership and teamwork
• Maintaining trust

Question 25

list the 4 sections that each domain of the CoO “Guidance for Professional Practice” contains

Answer 25

• Key points
• Detailed topic information
• Useful information and links
• References

You can find out how to manage someone

Question 26

how often is the CoO “Guidance for Professional Practice” updated

Answer 26

every 3 years (significant changes will be updated in interim)

Question 27

what does the CoO “Guidance for Professional Practice” set out

Answer 27

what is expected of optometrists in all work environments (multiple, independent, hospital)

If theres a case bought against an optometrist, then the court will refer to the college of optometrists guidelines

Question 28

what does the CoO “Guidance for Professional Practice” ensure

Answer 28

that Optoms put patients’ interests first, and work in partnership with them so they receive the best possible care

Question 29

by using the CoO “Guidance for Professional Practice” what are optometrists who use it responsible for

Answer 29

applying your professional judgement.You must be able to justify your actions if a complaint is made against you

e.g. patients vary and you may need to change your decisions/actions according to the situation

Question 30

what is the CoO “Guidance for Professional Practice” based on and what is it there for

Answer 30

the GOC’s standards and is there to support you in putting them into practice

Question 31

name a time when the GOC may take this CoO “Guidance for Professional Practice” into account

Answer 31

account in its fitness to practise processes (Bolam precedent)

Question 32

what are the 2 terminologies the CoO “Guidance for Professional Practice” uses

Answer 32

• must
  and
• should

Question 33

what is meant by ‘must’ in the CoO “Guidance for Professional Practice”

Answer 33

where you have a legal or regulatory obligation to follow the guidance (comes from the opticians act)

Question 34

what is meant by ‘should’ in the CoO “Guidance for Professional Practice”

Answer 34

where CoO would normally expect you to follow that course of action. If you apply your professional judgement and decide to take a different action, you must be able to justify your action.